Responding to humanitarian emergencies: MSF and the Rohingya refugee crisis

The actions of Doctors Without Borders/Médecins Sans Frontières (MSF) are first and foremost medical. This primarily consists of providing curative and preventive care to people in danger, wherever they may be. In cases where this is not enough to ensure the survival of a population — as in some extreme emergencies — other means may be developed, including the provision of water, sanitation, food, shelter, etc. This action is mainly carried out in crisis periods when a system is suddenly destabilized and the very survival of the population is threatened. — from the Chantilly Principles, MSF's charter of values

Responding to large-scale humanitarian emergencies has been at the heart of Doctors Without Borders/Médecins Sans Frontières (MSF)’s medical humanitarian action since the organization was founded nearly 50 years ago. Right now, one of MSF's largest and most urgent interventions is taking place on the border between Bangladesh and Myanmar, in response to one of the world's most challenging humanitarian emergencies: the Rohingya refugee crisis.

Nearly one year ago, on August 25, 2017, military forces in Myanmar carried out a brutal and targeted campaign of violence against Rohingya communities living in that country’s Rakhine State. The Rohingya have lived as an ethnic minority in Myanmar for generations, but have never been granted citizenship or even basic rights, and have been the subject of persecution for decades. Previous waves of violence had driven many Rohingya to seek shelter as refugees in neighbouring Bangladesh, but last summer’s attacks were unprecedented in their scope and ferocity: survivors have described whole families murdered or burned alive in their homes, along with other atrocities including rape and torture. The attacks created a displacement crisis that was itself unprecedented in scope and magnitude, as more than half a million Rohingya fled across the border in search of safety, almost all of them arriving in Bangladesh en masse within the space of a few short weeks last September.

What began as a violent assault on a targeted minority quickly became a massive and complex international humanitarian emergency. Those fleeing the attacks in Myanmar joined hundreds of thousands of Rohingya already displaced across the border in Bangladesh, resulting in a total population of close to one million people trapped along a tiny sliver of land, with little to no access to food, water, shelter or healthcare.

At the time, Doctors Without Borders/Médecins Sans Frontières (MSF) was already working to provide care to displaced Rohingya in Bangladesh, and had been for years assisting Rohingya communities on the other side of the border in Rakhine State. When the new crisis began last August, MSF immediately began scaling up activities in order to meet the massive increase in needs in Cox’s Bazar, the border region where most Rohingya refugees cross into Bangladesh.

Urgent care and outbreaks of disease

Since then, MSF has been at the forefront of the humanitarian response to the Rohingya refugee crisis in Bangladesh, mostly by providing urgently needed primary medical care to people who have been violently attacked and forced into desperate living conditions, and who had also been denied access to basic health services when still in Myanmar. MSF has helped contain outbreaks of disease in the dense and overcrowded displacement camps, including diptheria, a deadly illness that has mostly been eradicated elsewhere in the world but to which the Rohingya, who had never received regular vaccinations, are still dangerously susceptible. MSF also continues to work with a wide range of partners to provide critical water and sanitation measures in the camps, and to assess the most urgent needs through wide-ranging outreach activities and medical surveys.

One year on from the violence in Myanmar, and the Rohingya refugee crisis in Bangladesh remains a massive humanitarian emergency, with close to a million people confined to a small patch of land along the border between the two countries, dependent on humanitarian aid for their very survival. MSF medical teams are still working relentlessly to meet the urgent medical needs of this highly vulnerable group of people, and continuing to adapt to new challenges — such as the onset of monsoon season in the Bay of Bengal, which is putting hundreds of thousands of already desperate people at increased risk of injury, displacement or death as a result of floods and landslides.

Testimony: In the video above, Fatima Khatoun, a Rohingya refugee in Bangladesh, describes what drove her and hundreds of thousands of others to flee from Myanmar's Rakhine State.

MSF: intervening when 'the very survival of the population is threatened'

Responding to large-scale emergencies such as this lies at the heart of MSF’s medical humanitarian action. According to MSF’s Charter of Principles, “the actions of MSF are first and foremost medical. This primarily consists of providing curative and preventive care to people in danger, wherever they may be. In cases where this is not enough to ensure the survival of a population — as in some extreme emergencies — other means may be developed, including the provision of water, sanitation, food, shelter, etc. This action is mainly carried out in crisis periods when a system is suddenly destabilized and the very survival of the population is threatened.”

The Rohingya refugee crisis in many ways epitomizes the type of extreme emergency MSF’s medical humanitarian action is intended to help alleviate. The survival of the Rohingya people is under threat, and there remains no clear future for them. In Myanmar they remain at risk of extreme violence, while in Bangladesh they remain trapped in overcrowded displacement camps and entirely reliant on humanitarian assistance in order to simply live.

Until there is a sustainable political solution to this crisis, the Rohingya will remain in desperate circumstances — and MSF will remain on the ground to ensure they have access to essential care.

In July 2018, Joe Belliveau, the Executive Director of MSF Canada, travelled to Cox’s Bazar to visit MSF’s humanitarian medical operations in response to the Rohingya refugee crisis. Belliveau had overseen MSF’s activities on both sides of the border between Rakhine State and Bangladesh from 2009 to 2013, so was already familiar with the context, but his visit allowed him to see first-hand the new and specific challenges that last year’s events have created, and to meet with several Canadians working on the front lines of MSF’s crisis response.

The humanitarian challenge: Caring for nearly one million refugees as monsoon season approaches

In July 2018, MSF Canada executive director Joe Belliveau visited MSF's medical operations responding to the Rohingya refugee crisis in Cox's Bazar, Bangladesh. Close to 900,000 people, the majority of whom fled across the border from Myanmar last September, are seeking shelter in a small area prone to heavy rains in July and August.

In the video above, Joe describes the challenges of providing humanitarian care in such a setting.

"Hello, I’m Joe Belliveau, executive director of MSF, or Doctors Without Borders, Canada. I’m here in Unchiparang refugee camp, which is a camp for Rohingya refugees who fled Myanmar, most of them about nine months ago. Right now it’s the monsoon season. It’s weighing heavily on everybody’s minds. We just walked through a downpour ourselves, people are very worried about what the monsoon season could bring. You can see how people’s houses are set up: They’re very flimsy, they’re bamboo and plastic, and they’re perched up on high ground, so when the monsoons come, sometimes the houses can just slip down, sometimes on top of one another. Just over here there is one that’s exactly like that. So there’s the risk of injuries, we’ve had people injured, we’ve had one person at least who was killed that way. The monsoons are also bringing the risk of spread of disease. If you see the latrines that are down over there, you can imagine that, as the rains come, they funnel down into these ravines, they can sometimes overflow the latrines, and that can cause the spread of disease around the camp. So right now MSF is running a clinic just over the hill here, and treating all manner of diseases and injuries, including acute watery diarrhea … we’re seeing an increase of it, and we believe that is a direct consequence of the monsoons now, and the spreading of dirty water, and that’s a real risk for us at the moment."

Jonathan Skillen is a nurse from Barrie, Ontario, who has participated in MSF medical interventions in South Sudan, Democratic Republic of Congo and Syria. He is currently the medical team leader for MSF's emergency response in the Balukhali refugee camp in Cox's Bazar, Bangladesh. In the video above, he describes some of the conditions he and his colleagues are seeing in the camps and among the Rohingya patients they are treating.

"We’re looking at a population that was discriminated against, or kept away from the normal health system, so a population that isn’t used to accessing healthcare, and then you put close to a million people in a tiny camp, people are living on top of each other, where communicable diseases are spreading around very easily and very quickly; in the past we’ve already seen a measles outbreak, a diphtheria outbreak, we’re looking at the spread of mumps right now, so these vaccine-preventable diseases that are spreading from person to person really quickly. Now that we’re into the rainy season, the monsoon season, we’re seeing a lot of AWD, so acute watery diarrhea, especially in kids under five but also among adults. Even today when I was in the diarrhea treatment unit, we had three new patients admitted who were all adults, who have been sick for the last few days with profuse, profuse diarrhea, to the point where it’s dangerous. People are needing to get litres of IV fluid in order to be resuscitated. But I think we’re doing a really good job with the team that we have and we’re able to treat them."

"It’s really difficult to understand without seeing it, without seeing video or being in the camp the situation that people are living in. Families of five to 10 living on top of each other. There’s almost no open space other than the road you’re walking on, it’s just people living and breathing the same air all the time, it’s really close quarters, the water and sanitation in the camp is really … there’s been a lot of work done, but it’s still not perfect, the latrines that people are using are eroding away in the rain now, the water, there’s a lot of standing water that’s probably quite contaminated with garbage, which then obviously leads to a situation where waterborne disease can spread quickly."

Canadian nurse and MSF medical team leader Joanthan Skillen walks through the Balukhali camp for Rohingya refugees in Bangladesh.

'Literally saving lives every day'

"I think that people are where they feel safe right now. Going back to Myanmar, I mean it’s only a few kilometres from where the camp is, across the border, so you could go back but I don’t think people want to, they’re staying where they feel safe with their families."

"What I see is that MSF in the camps is a leader in the healthcare sector. We’re able to change and adapt really quickly to the needs of the population, so when we had the diphtheria outbreak, when we had the measles outbreak, we were able to set up extremely fast and react and to meet the needs of the population. MSF’s uniquely positioned in that way, able to bring in experts from all over the world, and really just work tirelessly and make sure we can provide at least the bare minimum, but hopefully a bit more."

"The difference that MSF is making by being here is not only literally saving lives every day, but also providing services that people would otherwise just not have. We’re providing emergency services, we’re providing in-patient, we’re providing out-patient, providing care to survivors of sexual violence, those are the things that we’re doing, with our doctors, our medics, our nurses we’re also I think restoring a bit of dignity to the lives of people who have been displaced across the border. We’re here, we’re seeing them, and we’re letting them know that we’re helping and we care about what’s happening."

Treating patients and preventing outbreaks of disease: Susan Phillips, a Canadian nurse at MSF's Kutupalong hospital for Rohingya refugees in Bangladesh

Last July, MSF Canada executive director Joe Belliveau visited MSF's medical operations for Rohingya refugees in Cox's Bazar, Bangladesh. On his visit he went to MSF's Kutupalong hospital, a facility that first opened in 2009 when an earlier group of refugees fled violence in Myanmar. At that time, Joe was overseeing field operations for MSF in Myanmar and Bangladesh. On this return visit he met with Susan Phillips, a Canadian nurse from the Toronto area who currently oversees infection prevention control in a place where outbreaks of disease remain a significant risk.

In the video above, Joe and Susan discuss the challenges of providing care to a vulnerable population, and how the situation has changed for Rohingya refugees as a result of the current crisis.

Joe: Hello I’m Joe Belliveau, I’m the executive director of MSF, Médecins Sans Frontières, or Doctors Without Borders Canada. I’m here at the Kutupalong camp and the hospital, the MSF hospital here in the camp, which is a camp for refugees here in Bangladesh. These are the Rohingya refugees who fled Myanmar, and most of the people who are here now would have fled Myanmar about nine months ago, following some extreme violence that occurred in Myanmar. I’m sitting here with Susan Phillips, she’s an emergency nurse from the Toronto area in Canada. [To Susan] I’m very pleased to be sitting here and talking with you today, and have the chance just to talk a little bit about what you do here and a little bit about what the situation is like. So perhaps you could introduce yourself a little bit more, and just describe what your role is here in the hospital.

Susan: My name is Susan, and I’m doing infection prevention control for the clinic here, as well as for the three health posts we have within the refugee camp where most of the settlements are. This involves basically maintaining waste management systems within the hospital, as well as medical infection prevention within the practice to improve quality.

Joe: What kind of infections would you be most worried about in a context like this?

Susan: Well right now, as we’re approaching monsoon season, we’re most worried about cholera. We do have other diseases here like tuberculosis, measles, we do see polio, chicken pox — actually a lot of the diseases that are treated are prevented from vaccinations, which this population doesn’t have, due to their displacement in Myanmar and probably their lack of healthcare there as well.

Joe: And so you talk about a potential cholera outbreak. Can you tell us what is cholera, and how might this become a big problem here?

Susan: Acute watery diarrhea is what we call that here. It’s a bacteria that’s found in the water system or food, and it’s transmitted by eating something that is already contaminated, and oftentimes people will just have a diffuse diarrhea, which can cause severe dehydration. If it’s not treated within a reasonable amount of time, then we see more complications with it, and the spread of it as well. It’s easily treatable with rehydration. We don’t give any antibiotics for this, we simply treat patients with ORS [oral rehydration solution], which makes it easily curable within this population, as long as we have waste management systems in place.

Joe: I was walking through some of the camps earlier today, and seeing how some of the latrines are perched sometimes on precarious slopes. It actually did rain on us quite a lot today, and so we could see how the drainage systems were working, and I guess when it does rain like that, and there are latrines that are overfull and that sort of thing, I guess that can really contribute to that kind of outbreak?

Susan: Definitely. There’s just under 900,000 people in this camp, so having adequate water and sanitation supply in the camp has been very difficult. I know MSF here also has a good watsan [water and sanitation] team, and is trying to build more latrines and water points to help. It’s very difficult to keep up with the amount of people that have come in, and other people that have been displaced because of the monsoon season and the landslides that have been happening, so we’re trying to play catch-up here, and that’s quite difficult. When we get significant amounts of rain, the drainage system, like you said and like you saw, it’s impossible to have proper sanitation there, and that’s how the bacteria spreads.

Patrick Rohr

Early morning in the waiting area at the MSF Kutupalong Clinic.

Joe: So last August was when this attack occurred, [and when people] came into this area, and there’s not much space here. There wasn’t much space before, and now they’re sort of all crowded just up and down the street just outside there, and all the way down to some of the other camps we were in today. … Where they can find the space at all for the people is unimaginable. There are many, many organizations here that are doing all manner of aid and activities — within all that, what do you think is MSF’s role?

Susan: Well, MSF has actually had one of the longest running clinics. This clinic here, Kutupalong, has been here for nine years, treating actually the host population, which is Bangladeshi, as well as the Myanmar population. This crisis is unfortunately not new, there have already been small amounts of Myanmar people coming here, but with the recent events, and when the large influx came in last August ... we’re trying to provide primary care, essentially, and we have a large OPD clinic here, an outpatient department, as well an emergency department, and then we have some services for maternity or birthing, as well as SGBV, or sexual and gender based violence, program as well, as we see a lot of that. We do also have an in-patient facility here, which has been the primary focus for Kutupalong clinic, treating pediatrics, [neonatal] and adult conditions, and then we have some small isolation for TB [tuberculosis] and measles, and we’re making some small space for the acute watery diarrhea.

Joe: So a whole range …

Susan: We have a huge range, and since the influx the scope has expanded quite significantly.

Joe: Just to give us an idea of the scale, how many staff are working for MSF right now?

Susan: Well for MSF let’s say per day here on site is 100 staff roughly, just under that. And if you want to think about the patients that we see, our OPD centre sees about 500 patients a day, and that’s not including the patients at our three outposts, and our inpatient wards we have a capacity for 107 people.

Joe: How many outpatients in a Toronto hospital, would they get in a day, do you think?

Susan: It depends on which hospital, but the hospital I work for we see about 250 patients a day. So this is double.

Joe: So 500 is quite a lot. I’m glad you raise the history a little bit, because this actual site has a special meaning for me, because I was one of the managers for MSF involved back in the period between 2009 and 2013. This place opened up in 2009 so I remember when it just started. It was a much more modest facility back then, and clearly it’s had to scale up a lot. And at that time, this whole problematic with the Rohingyas ... as you say, it’s not new, it’s a decades-old story, and we were also working very heavily on the Myanmar side at the time. We used to call it an open air prison, because people just couldn’t move around: they weren’t allowed to get married, they weren’t allowed to access healthcare freely, education, just to even move from one village to the next was very difficult, they were forced to labour, and so on and so forth. They were really intensely horrible conditions for them, and I think that’s one thing for us to keep in mind looking ahead here, is that this wasn’t just a moment in time, with just a moment of violence and then people can just go back. I think we have to start thinking ahead about what’s next. What are your thoughts? What’s the future? What’s next?

Susan: Well the future for us here at MSF is to continue doing our work. Continue treating our patients who come in and need our help, and bearing witness to what is happening, and go from there. It’s hard to predict the future. It’s always important to keep in mind what’s happening now as well.

Joe: And respond to the needs as they arise, and adapt.

Susan: Yes.

Patrick Rohr

Patient Assia, 21 days old, with her mother Mortuza, a Rohingya refugee, in the emergency room at MSF's Kutupalong clinic in Bangladesh. Assia is suffering from fever and breathing problems.

Joe: So even more generally, what is humanitarian action to you, what does it mean to you, and why are you part of MSF?

Susan: Humanitarian action for me is helping those in need, who can’t help themselves or who don’t have the ability because of restrictions that are placed on them from other people. Humanitarian action is to be there for them regardless of what’s happening on the other side, and the one thing with MSF is that we are neutral, and this is why MSF is good here, is that we don’t take sides, and we’re well and truly here for the people, and we help the people who require it. That’s really the main reason why I’m here.

Joe: You know Toronto is far from here, and it always gives me such a charge to come here and see you and your colleagues and what you’re doing, and to have a chance to walk through the wards and see that there’s such activity, and people are really coming in a desperate situation, in that they might not have healthcare any other way if it wasn’t for MSF being here. So it makes me very proud, and reminds me about what it is that we’re out here doing. I’ll ask you one last question, and that is what is your biggest concern now when you look at this whole situation?

Susan: [pause] It’s being able to maintain, being able to stay. There’s always the question of sustainability in places like this, whether or not we can continue our services, whether or not there’s enough support from the host country that’s allowing us to be here as well, and being able to support all of these people. It’s difficult if we don’t have the resources for that. That’s definitely I think the biggest concerns for me, is do we have enough for almost a million people, coming in every day with the numbers we see every day, and with the amount of different conditions we have — are the services we have, are they enough? I think that’s the biggest concern for me.